More GDN Background
A SERIES of fatal flaws that led to the Gulf Air disaster had been ignored for years, says a final report on the tragedy.
The airline failed to respond to safety warnings issued by its regulatory body, to attend international safety meetings, to provide adequate training in emergency procedures and to staff its flight safety department properly, says the final report by the Accident Investigation Board.
"The investigation showed that all of the latent organisational and management conditions that precipitated the accident to GF072 were present long before the accident," states the report.
"They had been identified and should have been rectified long before it happened.
"If these deficiencies had not been rectified, similar accidents could occur again, for the same underlying systemic reasons."
The agency responsible for the overseeing flight operations, the Directorate General of Civil Aviation and Meteorology (DGCAM), Oman, had repeatedly warned Gulf Air about its lack of compliance with Civil Aviation Regulations (CARs), according to the report.
During the three years preceding the accident, the DGCAM "could not achieve compliance by Gulf Air with respect to some critical regulatory requirements."
This was due to "inadequate supervisory oversight within Gulf Air, rather than a deliberate disregard for the regulations", said the report.
It said the airline did not emphasise Ground Proximity Warning System (GPWS) training, which would have trained Captain Ihsan Shakeeb to respond instantly to the warning that he was about to crash into the sea.
This is despite the fact that such training was originally introduced in the industry as defence against such Controlled Flight into Terrain (CFIT) accidents, which still account for the greatest number of airline fatalities each year, according to the report.
Gulf Air's flight data analysis system was not "functioning satisfactorily" at the time of the accident and this could have warned them that some flight crew were not complying with Standard Operating Procedures (SOPs), said the report.
The airline could then have taken action to ensure that SOPs were followed.
If Capt Shakeeb had complied with these procedures the accident would not have happened, noted the report.
Crew Resource Management (CRM) training, which was implemented at other airlines to increase safety, was apparently stopped in 1996 or 1997, when there was a change of management said the report.
"One of the goals of CRM training is to provide crew members with the tools to foster co-operative collaborative teamwork and overcome counterproductive styles of leadership and group interaction," noted the report.
"Such tools include assertiveness training for First Officers and participative management training for captains.
"The evidence shows that CRM in the cockpit of GF072 was ineffective, and that this contributed to the non-adherence to SOPs by the flight crew, which initiated the sequence of events that led to the loss of the aircraft."
Capt Shakeeb was found to be taking the lead in the cockpit at the time of the crash, while his co-pilot did not raise any alarms, perhaps because he was intimidated.
"At the time of the accident there was no formal CRM training programme within Gulf Air. The accident was consistent with that organisational deficiency," added the report.
"The value of CRM training to operational safety should and could, have been recognised by the company a long time ago."
The airline also failed to provide adequate CFIT training.
Gulf Air had a one-man safety department from 1998 to the time of the accident.
"This lack of resources within the flight safety department and its inappropriate corporate status within the company was a serious deficiency," said the report.
The airline had stopped taking part in the International Air Transport Association (IATA) Safety Committee meeting years before the crash, it added.
"This greatly restricted the airline's awareness of new information and developments in areas such as accident investigation studies, safety and risk management programmes, training, safety information systems and safety management programmes."
It has now resumed its participation in the meetings.